FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICcS ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 (209)468.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Tripl'K:ate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI CJ C,J �j�/ t'C1_i C)`�1 CITY 1 r c\�-�I \ L PARCEL SIZE/APN/ ��'7' OWNER'S NAME �'' i tt .' S ^C.1 .�� L l tlTl \\ 1L S-7 12 ` 0 ADDRESS Com.C.+ 1 D Z PHONE I ] 7 CONTRACTOR t.'�J C.`.l�-i \ J�_�J GL� n\\�1"/� tJ S ADORES6,�O� \ -C� PHONE SUB CONTRACTOR ADDRESS 0-A `�T i LIC/ PHONE J t TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑MONITORING WELL/ 1ppp❑��(OTHER ��INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR {q EXTRACTION WELL J N_0 R-1, H.P. 1 ] 1�j DEPTH PUMP SET�FT. FIRST WATER LEVE p ITYPE OF PUM ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL/ ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC ATION6 It 17 ALX El INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 11 `��ii DIA.OF CONDUCTOR CASINO DC' ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SPE TYPE Of CASING/STEEIJPVC -4C DIA.OF WELL CASINO R I D� ❑RIBLIC/MUNICIPAL .L2❑51 DRIVEN DEPTH OF GROUT SEAL 0 '� SPECIFICATION ❑IRRIGATION/AG y,J OTHER ��t t�'to 1...� GROUT SEAL INSTALLED BY� GROUT BRAND NAME E El MONITORING -Y I GROUT SEAL PUMPED:�1 Yee N. CONCRETE PEDESTAL BYDRILLER:%Y- ❑No St ; APPROx.DEPTH J17 LOCKING JCHESTER BOX/STOVE PIPE 5I• PROPOSED CONSTRUCTION/DISLUNG METHOD: MUD ROTARY AIR ROTARY A AUGER CABLE OTHER G I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANIt, REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHA pT\EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA-' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING' 'I C LLAT 11t THE PERFORMANCE OF THE WO.FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'.COMPENSATION LAWS OF CALIFORNI . T C N �j V.T GIALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001465.3423.COMPLETE DRAWING AT LOWER AREA PROVIDED. SiSned x ♦ .J..- - Tltle l-'r-7 Z L\ \'L�CP ' D.te JZ r, L PLOT PLAN 10—to S1Nc1 Scels _'to C h 1 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. �� c�� r✓ov� N�Y1�+I�N'' , c' ..,r} � ........ 1996 DEPARTMENT USE ONLY - Appllcetlon Accepted BY 'fiL'c-t Dets (` qty �j Gr—1—tion By Dete10- Pump I-P-1-By Dete De.tr�ctlen ImPectlon BY Det Comment.: p - oil 11 - 74s -- 41' a, rOJV L1�JJ k� I �,om i SGVY/'L/ IA�iI( (l )v sw.r�ce ACCOUNTING ONLY: AID/ FACT LLI Iti� 5I0.1 PE CODES FEE INFO AMOUNT REMITTED CHECK!/ A.H RECDV ED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE CJ' ji vo2-7